Care Home: The Court

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What the care home does well Care services are offered in a comfortable, homely environment, and provide a good response to the needs, and preferences, of the Residents and their relatives. Particular strengths are the provision of meals and a range of activities well matched to resident`s capabilities and preferences. Particularly noteworthy is the stability of the workforce with many staff having served the home for many years. What has improved since the last inspection? Following the purchase of The Court by Southern Cross Healthcare, there are clear signs of improvements having already been achieved, e.g. in respect of; meals provision, staff training, staff supervision, care planning documentation and records, care equipment, installation of fire door guards. In addition, there are well-structured plans in place for further development, particularly in respect of refurbishment and redecoration of the environment. What the care home could do better: Notwithstanding the two recommendations made at the end of this report, given the new ownership and new management, and the wide range of improvements already achieved, and planned, at this juncture we feel it neither productive or necessary to identify specific areas for improvement. We are satisfied the one area of care requiring specific attention, i.e. environment, has been recognised and is currently being addressed. CARE HOMES FOR OLDER PEOPLE The Court West Felton Oswestry Shropshire SY11 4LE Lead Inspector Keith Salmon Key Unannounced Inspection 16th April 2008 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Court DS0000071084.V364220.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Court DS0000071084.V364220.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Court Address West Felton Oswestry Shropshire SY11 4LE Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01691 610626 01691 610543 www.southerncrosshealthcare.co.uk Southern Cross BC OpCo Ltd Kym Wright (currently applying for registration) Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36) of places The Court DS0000071084.V364220.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home with Nursing - Code N To service users of the following gender: Either Whose primary care needs on admission to the Home are within the following category: Old Age, not falling within any other category, Code OP - maximum number of places 36 The maximum number of service users who can be accommodated is: 36 23 July 2007 2. Date of last inspection Brief Description of the Service: The Court Care Centre, recently purchased by Southern Cross Health Care, provides personal and nursing care for up to 36 people. Situated in the quiet village of West Felton, near Oswestry, the Home maintains active links with the local community. The property comprises a large country house, converted in the 1980s to provide suitable accommodation for residential care with a more recently added purpose built extension enabling the provision of nursing care. The home, which benefits from pleasant grounds, with pleasant views of the surrounding countryside, provides one large lounge, two lounge/diners, two dining rooms, 32 single rooms (8 ensuite), and two shared rooms. Fees charged weekly are set out in the Home’s general information and are in the ranges - £370 to £460 (residential) and £510 to £600 (nursing). The precise amount charged is determined following assessment. The Court DS0000071084.V364220.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. This Unannounced ‘Key’ Inspection commenced at 9.30am, concluded at 5pm, and was conducted by Mr Keith Salmon, representing the Commission for Social Care Inspection (CSCI). Present, on behalf of the Home, was the Manager, Ms. Kym Wright. This Report is based on observations made during a tour of the Home, a review of care related documentation, staff files and duty rotas, plus a range of other documents/records reflecting the general operation of the home. The report also utilises information submitted by the home through a very detailed and comprehensive Annual Quality Assurance Assessment (AQAA), which provided a useful framework for us to evaluate quality of service and progress made. The Inspector also held individual discussions with 7 Residents, 1 Visitor, the Manager, and several other members of staff, including nursing and care staff, Deputy Manager, the Administrator, Chef, and Maintenance Man. What the service does well: What has improved since the last inspection? Following the purchase of The Court by Southern Cross Healthcare, there are clear signs of improvements having already been achieved, e.g. in respect of; meals provision, staff training, staff supervision, care planning documentation and records, care equipment, installation of fire door guards. In addition, there are well-structured plans in place for further development, particularly in respect of refurbishment and redecoration of the environment. The Court DS0000071084.V364220.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Court DS0000071084.V364220.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Court DS0000071084.V364220.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, & 3 (6 - not applicable). Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People wishing to move into the home are provided with information to assist them in making an informed decision. Processes to ensure appropriate and thorough care needs assessment, prior to admission, are effectively applied, and subsequent findings are utilised to ensure appropriate placement and care provision. EVIDENCE: All information for prospective Residents is currently subject to review following the recent change of ownership. However, we were able to observe the final draft of the Service User Guide, which is expected to be printed and available in the coming weeks. This is in accordance with requirements. Review of care plans, and related documentation, demonstrated appropriate and thorough care needs assessment is undertaken by the Manager or Deputy Manager, prior to admission. The Court DS0000071084.V364220.R01.S.doc Version 5.2 Page 9 Information gathered is utilised to enable an informed decision regarding the home’s capability of meeting individual care needs of each prospective Resident. Although prospective residents had not previously received a letter confirming the home’s capability in meeting assessed care needs the Manager assured us this would be implemented, under the new ownership, for all new admissions. The Court DS0000071084.V364220.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, & 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The model of Care Plan utilised by the Home is comprehensive, easy to follow and current. Care provided by the Home is very effective in meeting the Residents’ assessed care needs, and is delivered considerately. Residents are treated with respect, their privacy and dignity upheld. The storage, administration, and disposal of medicines are in accordance with accepted good practice. EVIDENCE: Since the previous inspection, the care planning documentation has been changed so as to be in line with the corporate model used elsewhere within the Southern Cross Group. The transfer of care planning information for existing Residents from the ‘old’ to the ‘new’ model has been completed. The Court DS0000071084.V364220.R01.S.doc Version 5.2 Page 11 Review of care planning documentation relating to four Residents selected at random for ‘case tracking’, demonstrated the design to be robust, comprehensive, and applied effectively in meeting Residents’ individual care needs. Areas of care addressed by the care plan now include; full range of risk assessments based on ‘activities of daily living’; pressure sore risk assessment; nutritional state, including daily food and fluid intake; regular weighing (frequency determined by assessed need); records of visits by clinical/social care professionals, e.g. GP, Community Nurse, Social Worker, Optometrist. Residents’ interests, hobbies, and preferences are also recorded. Evidence was also observed of involvement by residents/’supporters’ in the needs assessment, and care planning process, together with regular review (at least monthly) and with change where necessary. The home operates a system by which residents are allocated both a ‘named nurse’ and a member of care staff designated as their ‘key worker’, with all staff encouraged to make written entries in the daily record of each resident. A review of the policies/procedures relating to the management/administration of medicines was undertaken, i.e. records relating to the supply, storage, and disposal of medicines (including records of ambient and medicine refrigerator temperatures), the maintenance of medicine administration records (MAR Sheets), and the maintenance of the Controlled Drugs Register. In addition, the contents of the medicine cupboard, and systems/records relating to the receipt and disposal of medicines were examined. Inspection of medicine storage provision, administration records, and practices for disposal of ‘unwanted’ medicines demonstrated the Home’s practices meet the guidelines of the Royal Pharmaceutical Society. The Court DS0000071084.V364220.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are enabled to choose their life style, social activity and to keep in contact with family and friends. The range of activities offered is consistent with individual resident’s capabilities and expectations. Opportunities for contact with family/friends/community are established and encouraged. The Home provides a daily choice of attractive and nutritious meals based on Residents’ preferences. EVIDENCE: The planning, and organisation, of social and leisure activities is the responsibility of a long-serving member of care staff, who dedicates a minimum of 15 hours per week to this task. Whilst most of this time is applied during Monday to Friday, some time is deployed for special events held in the evenings, at weekends, and Bank Holidays. The Court DS0000071084.V364220.R01.S.doc Version 5.2 Page 13 The main responsibility is in the planning of the activities programme, together with their implementation, and in recruiting assistance from available staff, on a day-to-day basis, dependent on staff numbers and overall workload. Particular attention is given to ensuring residents enjoy leisure/social activities consistent with their individual preferences and capabilities. In our discussions with residents and relatives a number confirmed the home provides a variety of activities, and pastimes, consistent with meeting their needs. Evidence of this was observed in the detailed activities record maintained for each resident. Specific examples of activities reflected in the home’s published programme, individual care plans, and through comments made to us by residents/ relatives, include; art classes, craftwork sessions (residents had recently been involved in making clay models), exercise and ‘musical movement’ sessions, reminiscence, visiting singers and choirs, and outside speakers covering a range of subjects. Residents also have the opportunity to join shopping trips, canal boat trips, and train trips. The Manager informed us she is investigating the possibility of the home having its own minibus to enable greater flexibility, and access to a wider range of activities. The home encourages and welcomes visitors, and one relative, who is a frequent visitor, commented, … ”They look after my Relative very well, and make me really feel part of the caring process.” A four weekly menu is operated giving service users a choice of meals each day for lunch, plus a wider choice if necessary, with the opportunity for drinks and snacks throughout the day. Residents commented to the Inspector how much they enjoyed the food, both the quality and quantity. We were told of the recent introduction of the ‘Nutmeg System’ (used throughout Southern Cross care homes). This involves input of meals data onto a computer, which then assesses the balance/quantity of food to help ensure residents receive a nutritious diet. We observed that particular attention is provided in helping residents who need assistance with eating. The Court DS0000071084.V364220.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 &18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The interests of Residents are protected through ready access to information relating to advocacy services and the home’s Complaints Procedure. Staff are aware of their role in protecting Residents from abuse and of taking appropriate action should it be necessary. EVIDENCE: CSCI has received one complaint relating to the home since the previous Inspection held in July 2007. The matter was handled in accordance with ‘Southern Cross’ policies and procedures, with documentation providing a full record of the complaint, action taken, and a satisfactory resolution. Residents and visitors, who spoke with us, stated they had no concerns, or complaints, but would feel very comfortable raising matters with the Manager or staff at any time. Information from various authorities regarding adult protection/’whistle-blowing’ is on display on the notice board. Staff training records evidenced an ongoing programme of staff training in relation to complaints and the protection of vulnerable people. Accident Records were reviewed and found to be current, presenting no areas for concern. The Court DS0000071084.V364220.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,21 & 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst the home provides a safe, homely environment the communal rooms and corridors in several places are looking rather worn and in need of refurbishment/redecoration. The number, and positioning, of bathrooms and toilets in current use are sufficient to meet resident’s needs. Specialist equipment, consistent with meeting the assessed care needs of service users and the demands of tasks carried out by care staff, is appropriately serviced and maintained. EVIDENCE: As indicated in the ‘judgement’ above, many areas of the home are looking rather tired and worn – e.g. some areas of skirting board and door jambs have The Court DS0000071084.V364220.R01.S.doc Version 5.2 Page 16 very badly damaged paintwork, and many window frames are in need of repair or replacement. This situation is recognised by the Parent Company as the Company’s Estates Director had recently visited to review the home. Through discussion with the Manager this visit has resulted in an action plan to improve the environment. Further meetings are to be held to identify priorities and establish a written programme with target dates for completion. However, initially it has been agreed there is need for short to medium term improvements, which will comprise the following:• • • • • Painting of all ground floor hallways (including paintwork to doorframes and skirting boards damaged due to passing wheelchairs, and trolleys) Fencing of the bin area Repair of window frames Cleaning and painting of guttering General tidying up of trees/shrubs Other areas planned for improvement will include – • • • • • Replacement of curtains, carpets and furniture New telephone system Installation of additional electricity plug sockets Relaying of tarmac/gravel Purchase of a ‘Rotowash’ machine (to enable more effective floor/carpet cleaning) We were further advised of plans to change the function of some areas of the home, currently designated as toilet and bathroom areas. Specifically:• • Removal of the first floor bathroom, which it is proposed to replace with a ‘hairdressing salon’ Removal of a ground floor toilet to enable better provision for food storage Whilst the provision of such facilities may be desirable the Manager was made aware of the need to discuss such proposals with CSCI, as the original Registration included agreement on the number, and position, of toilets and bathrooms. However, based on discussion with the Manager, and observations during this inspection, it is accepted these toilet and bathroom facilities are not used, and there removal will not disadvantage either residents or staff. Furthermore, residents told us they would very much appreciate a properly fitted out, on-site hairdressing salon. It is recommended details of the proposed changes are made known to the ‘Link Inspector’ for the home, as soon as possible, in order that formal discussion and possible agreement to these changes be established. The Court DS0000071084.V364220.R01.S.doc Version 5.2 Page 17 Quotations were observed relating to some of the above works, with quotations for the remainder currently being sought. Despite the worn appearance of the home the standard of cleanliness and hygiene is good. The Court DS0000071084.V364220.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff numbers on duty, and skill-mix, were sufficient to meet the assessed care needs of current Residents. Recruitment and employment practices are consistent with the safeguarding of Residents. The commitment of the Home in providing training for Care Staff is good, and in accordance with individual staff member’s learning needs. EVIDENCE: A review of recent duty rosters, and staff numbers/deployment at the time of the Inspection, suggested staff cover is sufficient to meet Residents’ assessed care needs. The Manager is usually supernumerary. Staff employment files relating to the three most recently employed staff were reviewed, and demonstrated recruitment practices to be satisfactory, with all elements required by Care Homes’ Regulations being completed, and evidence retained on file. The Court DS0000071084.V364220.R01.S.doc Version 5.2 Page 19 Staff training files evidenced the proportion of care staff, who hold National Vocational Qualification Level 2, or higher, comfortably exceeds the minimum 50 required by the Standard, i.e. 78 of care staff have attained Level 2 (including eleven staff who have attained Level 3, and one Senior Carer who has attained Level 4). Files further evidenced staff have undertaken appropriate induction training, plus mandatory training, including - moving and handling, medication administration, adult protection, care planning, risk assessment, infection control, and fire awareness. A matrix was observed, which clearly sets out completed training, and training planned for the future. With regard to ‘moving and handling’ skills, it was recognised by the new Manager that staff had fallen behind in respect of ‘update’ training. Evidence was seen confirming this has now been remedied. The Court DS0000071084.V364220.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36, and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A suitably qualified and experienced person manages the home. Transactions involving expenditure of Resident’s personal monies are safeguarded by the financial procedures operated within the Home. The systems for consultation with Residents have improved, with evidence suggesting their views are acted upon. Health, safety, and welfare of service users, and staff, are promoted fully by safe working systems being in place. The Court DS0000071084.V364220.R01.S.doc Version 5.2 Page 21 EVIDENCE: Since the previous ‘key’ inspection the home has had a change of ownership and a change of manager. Ms. Kym Wright has been appointed Manager and is currently seeking formal Registration by CSCI. Ms. Wright is an experienced Registered Nurse with some years of management experience having been Registered Manager, in her immediately previous post, at another care home. As might be expected the home is undergoing a series of changes, including the introduction of ‘corporate systems’ utilised by the new owners, ‘Southern Cross Healthcare’, e.g. in respect of residents’ information, care planning documentation, full range of policies and procedures, staff training, management structure. Comments from Residents, Staff and Visitors, and our own observations, suggest these changes are being very well managed. In achieving this, Ms. Wright is well supported by senior managers and directors of ‘Southern Cross Healthcare’. Evidence of this is seen in the Internal Improvement Plan drawn up, in April 2008, jointly by the Operations Director, Operations Manager, and the Home Manager. This addresses all aspects of care provision covered by Regulation, identifies areas of concern/shortfall, and has prospective target dates for completion. Ms. Wright (who is generally supernumerary), heads the management organisational structure within the Home, is supported by a Deputy Manager, and a recently appointed Financial Administrator. The parent company’s Project Manager undertakes an unannounced inspection visit at least monthly, and the reports of those visits were observed. The reports include details of a tour of the home, review of records (including audit of financial and medicines practices) and interviews with residents, relatives, and staff. Evidence was also seen confirming the organisation is working hard to gather the views of interested parties with regard to the quality of the service provided at The Court. Activities include:• • • Satisfaction surveys issued to residents and relatives Analysis and report on findings from surveys by the Operations Manager together with related action plans Quarterly meetings between representatives of the home and residents/relatives The Court DS0000071084.V364220.R01.S.doc Version 5.2 Page 22 Examples of recent action taken in response to matters raised through the questionnaires, and/or meetings include:• • • • • Provision of lunch at an earlier time (i.e. 12.30pm instead of 1pm), Moving of light switches previously mounted on the wall outside the toilets to pull switches within Larger flat screen televisions to facilitate ease of watching Monthly Holy Communion Ongoing adjustments and innovations in respect of the activities programmes Residents commented they felt they were influential in effecting positive changes in care provided at the home. Policies and procedures within the home are regularly reviewed and generally in line with current good practice. Where residents or relatives request it the home will hold a small sum of money to be used for such items as the weekly hairdresser or other incidentals. Examination of related records, and retained amounts of cash, evidenced arrangements to be robust, in order, with regular audit carried out as part of the regular unannounced inspection visits by the Projects Manager. A review of staff personal files, and related records, demonstrated Staff are subject to regular supervision. All systems such as fire alarms, emergency lighting, gas, and electricity are regularly maintained, checked as required with certificates to evidence this. Accidents are reported appropriately and there are risk assessments in place for ensuring safe working practices. The Environmental Health Officer inspected the home on 25 March 2008, and ‘Requirements’ as follows:• • The need to renew or repair an area of plaster in the kitchen. The need to repair/redecorate the paintwork of a window sill in the kitchen. These works have been satisfactorily completed. • Wooden slatting, fixed to the floor of the food storage room to provide shelving, was preventing proper cleaning of the underlying floor. It was observed the fixing screws have been removed allowing the slatting to be removed thus facilitating cleaning. At the time of this inspection it was seen the underlying floor was clean. The Court DS0000071084.V364220.R01.S.doc Version 5.2 Page 23 Records showing regular testing of hot water outlets accessible to residents were seen – these showed temperatures to be in accordance with the Standard i.e. ‘about 43o Celsius. It was noted that hot water outlets at wash hand basins in the laundry, and in the two sluices, do not have the benefit of thermostatic regulators. As a result the temperature of water coming from these outlets is too hot to permit adequate hand washing, without first mixing water in the basins to reach an equable temperature. It is recommended, to facilitate ease of staff washing their hands in these areas of increased cross infection potential, that thermostatic valves be fitted. The Court DS0000071084.V364220.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 3 X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 X 3 The Court DS0000071084.V364220.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP21 Good Practice Recommendations It is recommended details of the proposed building work, involving the conversion of the first floor bathroom and the ground floor toilet to change of use, are made known to the ‘Link Inspector’ for the home, as soon as possible, so that formal agreement to the changes may be established. It is recommended that thermostatic valves be fitted to the wash hand basin taps in the laundry room and sluice rooms to facilitating ease of washing of hands in these areas of increased cross infection potential. 2. OP38 The Court DS0000071084.V364220.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Court DS0000071084.V364220.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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